Healthcare Provider Details

I. General information

NPI: 1982052379
Provider Name (Legal Business Name): KATHERINE PUCKETT PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ELISHA AVE
ZION IL
60099-2676
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099-2676
US

V. Phone/Fax

Practice location:
  • Phone: 847-872-6450
  • Fax:
Mailing address:
  • Phone: 847-872-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.007061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: